) )ss: COUNTY OF ______________________ ) STATE OF SOUTH DAKOTA IN CIRCUIT COURT ______________ JUDICIAL CIRCUIT ******************************************************************************* In the Matter of the Petition of ) ) _________________________________ ) CIV: _______________ (Current Name) ) ) VERIFIED For a Change of Name to ) PETITION FOR ADULT NAME CHANGE ) ___________________________________ ) (Proposed Name) ) ) ******************************************************************************* COMES NOW Petitioner and does hereby state, under oath as follows: 1. Petitioner's current name is __________________________________________________. 2. Petitioner's full name, as it appears on Petitioner's birth certificate, is _________________ _____________________ _________________________________________. 3. Petitioner is an adult ________ years of age; date of birth: __________________________. 4. Petitioner's gender at birth was: male / female. 5. Petitioner was born in _______________________, ___________________ County, State of ____________________________________. 6. The full maiden name of Petitioner's mother is ______________________________. 7. The month, day and year of Petitioner's mother's birth was ______________________ and she was born in ____________________, _______________________ County, State of ________________________. 8. The full name of Petitioner's father as it appears on Petitioner's birth certificate is ____________________________________________________________. 1 Form UJS-025 Verified Petition for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com 9. Petitioner's father was born on the ________ day of _____________________, _________ and he was born in ____________________, _______________________ County, State of _________________________. 10. Petitioner's street address is __________________________________________________, __________________ County, South Dakota. 11. Petitioner has been a resident of __________________ County, South Dakota for more than six months prior to filing this petition. 12. The reason for wanting the name change is: _____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13. This petition is made in good faith, I do not intend to defraud anyone, and it is not done for the purpose of hiding my identity from any person, creditor or governmental agency of any kind or as to avoid discovery by such person, creditor or governmental agency. 14. I request that my name be legally changed from __________________________________ ______________________________________ to _________________________________ ______________________ ________________________________________. 2 Form UJS-025 Verified Petition for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com Dated this ______ day of _______________________, 20_______. _____________________________________ Petitioner (Signature) _____________________________________ Print your name _____________________________________ Street address _____________________________________ City, State, ZIP code _____________________________________ Telephone Number VERIFICATION STATE OF SOUTH DAKOTA COUNTY OF ________________ ) : SS ) Petitioner, being first duly sworn, deposes and states that he or she verifies the facts expressed within the Verified Petition for Adult Name Change are true. Dated this ______ day of ___________________, 20_____. _____________________________________ Petitioner's Signature Subscribed and sworn to before me this ______ day of ______________, 20____. _____________________________________ Notary Public/Clerk of Court (SEAL) If Notary, my commission expires:_____________ 3 Form UJS-025 Verified Petition for Adult Name Change Rev. 06/2011 American LegalNet, Inc. www.FormsWorkFlow.com